Comprehensive improvement of infection prevention practices in Ethiopia: Further refining the Lifebox Clean Cut program

Author(s):
Nichole Starr; Assefa Tesfaye; Natnael Gebeyehu; Jared Forrester; Thomas Weiser; Tihitina Negussie

Background:

Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low resource settings. Clean Cut is a quality improvement program co-developed by Lifebox and Ethiopian champions focused on reducing postoperative infectious complications by strengthening adherence to infection prevention standards embedded in the WHO Surgical Safety Checklist.

Hypothesis:

Initially implemented in three hospitals in Ethiopia over 2 years, it was refined using peer-to-peer learning strategies.

Methods:

Following successful Clean Cut pilot testing, the implementation strategy was refined and modified to a six-month intervention after interviews and facility-level meetings with all involved perioperative staff. A revised strategy of peer-to-peer mentoring was employed to build capacity and leverage local experience and relationships to encourage sustainable change. Subsequently the program was introduced in two additional Ethiopian hospitals. Adherence to Clean Cut standards were continuously monitored and 30-day outcomes obtained for all enrolled patients.

Results:

Modifications included 1) creating a local mentor relationship between a tertiary referral hospital and primary hospital, 2) emphasizing active hospital administration participation and engagement of entire operating room (OR) staff in discussions, 3) establishing a platform for shared learning, and 4) instituting supplementary educational trainings reinforcing critical infection prevention standards. Compared to baseline (n=92), adherence to standards improved significantly post-program implementation (n=609). Appropriate use of the WHO Surgical Safety Checklist, proper hand decontamination, sterility indicator use with instruments and surgical linen all improved (Table 1). Additionally, prophylactic antibiotic administration in the OR (rather than prior to entering) increased from 11% to 34% (p<0.001). Inpatient surgical site infections (SSI) significantly decreased (6.5% to 2.3%, p=0.02); there was a nonsignificant decrease in all inpatient infectious complications (9.8% to 5.4%, p=0.10) and overall complications (11% to 7.7%, p=0.30).

Conclusions:

A modified implementation strategy for the Clean Cut program focused on local mentorship and larger team discussions improved communication, allowing for more rapid uptake through multidisciplinary process change. Adherence to recognized infection prevention standards improved with an associated SSI reduction. Larger scale implementation with further refinement highlighting established mentor hospitals could improve infection prevention practices in Ethiopian ORs and reduce postoperative infections.